1. Personal Information Gender: Religion: Community** (SC/ST):

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1 INDIAN COUNCIL OF MEDICAL RESEARCH Ansari Nagar, New Delhi Application for the post of : Scientist 'D' or Scientist 'E' or Scientist 'F' (separate application for each post) Advt No: ICMRHQ/Pers/2018/2 Closing Date: 7th December, 2018 (Friday) Name of the Candidate: PART-I 1. Personal Information Gender: Religion: Community** (SC/ST): Age as on 7th December, 2018 (Friday): Father/Guardian Name: Are you Differently abled Person (PWD)?**: Are you ICMR Permanent Employee? ** Date of Birth *: Are you Govt. Employee?** Nationality: Are You Abroad Resident?**: * Enclose proof **If yes, pls enclose proof

2 Address: Taluk: State: Residence Ph: Mobile: 2. Communication Address: Post: Distt: Pin Code: Office Ph: Address: Taluk: State: 3. Permanent Address: Post: Distt: Pin Code: DD no. Date Name of Issuing Branch: 4. Payment Details ( if any) Amount: Bank Name: Bank Branch Code: 5. Educational Qualifications: (with proof) Exam passed Subjects Examination Authority 5(a). Academic Qualifications Name, Address of the School/College/Unicversity Month, year of passing % of marks

3 5(b). Essential Qualifications (as per advertisement) Exam passed Subjects Examination Authority Name, Address of the School/College/Unicversity Month, year of passing % of marks Exam passed Subjects Examination Authority 5(c). Desirable Qualifications Name, Address of the School/College/Unicversity Month, year of passing % of marks Employer name & address Post Held 6. Employment Details: (with experience certificate/proof) Nature of Period Period Responsibility Employment From To Pay Level in Pay matrix Present Pay/ Consolidated Pay

4 Part-II ANNEXURE Details Whether enclosed (Yes/No) I Publications II Research Experience III Academic & other Achievements IV Awards & Prizes V Membership of Editorial Board of Journals VI Institutional Administrative Responsibility VII Membership of Expert committee/governing Councils VIII Membership/Fellowship of National/Intenational Body IX Extramural Grants ANNEXURE I - Publications Publications Details 1 Total No. of Publications : 2 10 best Publications (as per details below) (Extracts to be enclosed) : S.No Journal Name Title and Author details Year of Publication Authority Type (First Aurhor/ Corresponding Author/ Coauthor) whether Indexed or not?

5 ANNEXURE II - Research Experience Research Experience Details S.NO Research Area Research Details Academic & other Achievements S.No. Achievements Details ANNEXURE III - Achievements S.No. Award/ Prize Type (National or International) ANNEXURE IV - Awards-Prizes Awards & Prizes details Award/Prize Name Awardee/Patente Award Descriptions of Year Awards/Prizes Annexure V - Membership of Editorial Board of Journals

6 Membership of Editiorial Board of Journals details S.NO Journal Name Impact Factor Description Details S.No Name of the Committee Annexure VI - Administrative Responsibility Institutional Administrative Responsibility Responsibility in Description/ Details Committee Annexure VII - Membership of Expert Committee Membership of Expert Committee/Governing Councils S.No Name of Govt. Body/Institution Description/ Details

7 S.NO Membership/ Fellowhsip Annexure VIII - Membership /Fellowship Membership /Fellowship of National/International Body Type of Name of Academy/ Descriptions of Awards/Prizes Academy Govt. Body (National/ International) Extramural Grants S.No. Grants Project Title Duration Role (PI or Co-PI/ Coordinator or Co- Investigator ANNEXURE IX - Extramural Grants Funding Agency Name Amount in Lakhs Declaration I.. hereby declare that all the details furnish above are true to the best of my knowledge and belief. Date: Place: Signature of the Candidate Part III (To be filled by Cadre Controlling Authority of the applicant) OFFICE OF..

8 1. Certified that the particulars given above by the applicant are correct as per records available in the Department/Office of It is also certified that Shri/Ms. is clear from vigilance angle and no disciplinary proceedings are pending or contemplated against him/her. 3. It is hereby certified further that this Department /Office shall have no objection to the relieving of said officer, in case Shri/Ms... is selected for the post of... in ICMR. (Name, Signature & Telephone No. of Officer with Official Stamp)

(APPLICATION FORM FOR SCIENTIFIC POSTS) Affix No column(s) should be left blank. Note: All answers must be given in words and not by dashes and dots.

(APPLICATION FORM FOR SCIENTIFIC POSTS) Affix No column(s) should be left blank. Note: All answers must be given in words and not by dashes and dots. 1 NATIONAL INSTITUTE OF MALARIA RESEARCH Indian Council of Medical Research, Department of Health Research, (Ministry of Health & Family Welfare), Sector-8, Dwarka, New Delhi 110077. Website:- ICMR:- www.icmr.nic.in